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THE  TREATMENT  OF  CAVERNOUS  AND 

PLEXIFORM  ANGIOMATA  BY  THE 

INJECTION  OF  BOILING  WATER 

WYETH  METHOD 


REDER 


ifxTTrT 


Columbia  ZSJmbenSttp 
intJje€its>of35eto§9orfe 

College  of  ipfjpstdans  anb  burgeons 


Reference  Htbrarp 


THE  TREATMENT  OF  CAVERNOUS  AND  PLEXI- 

FORM  ANGIOMATA  BY  THE  INJECTION  OF 

BOILING  WATER    (WYETH  METHOD) 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatmentofcaverOOrede 


Plate  I. 
A   typical   cavernous   angioma   of  the  left  clieek   and   upper  lip. 


THE  TREATMENT  OF  CAVERNOUS  AND 

PLEXIFORM  ANGIOMATA  BY  THE 

INJECTION  OF  BOILING  WATER 

(WYETH  METHOD) 


BY 
FRANCIS  REDER,  M.D.,  F.A.C.S., 

VISITING     SURGEON     TO     CITY     HOSPITAL;     CONSULTING     SURGEON     TO 

ST.    JOHN'S    HOSPITAL    AND    MISSOURI    BAPTIST    SANITARIUM, 

ST.    LOUIS. 


ILLUSTRATED 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 
1918 


Copyright,   131S,   by   C.    V.   Mosby    Company 


Press  of 

C.   V.  Mosby  Company 

St.  Louis 


TO  MY  WIFE 

WHO  HAS  SHARED  WITH  ME 

THE  "MIDNIGHT  OIL" 


PREFACE 

Perhaps  no  apology  is  necessary  for  the  appear- 
ance of  this  monograph  in  brochure  form. 

An  excuse,  however,  may  be  offered  on  the 
grounds  that  a  liberal  supply  of  reprints  has  been 
exhausted,  and  though  the  original  article  ap- 
peared in  Surgery,  Gynecology  and  Obstetrics 
nearly  three  years  ago,  requests  for  reprints  are 
still  being  received.  It  is  the  best  attestation 
whereby  the  value  of  the  procedure  embodied  in 
this  brochure  is  to  be  judged.  Furthermore,  it 
conveys  the  conviction  that  physicians  are  alive 
to  appreciate  what  appears  in  medical  journals  of 
high  standard.  A  subject  of  special  interest  will 
usually  engender  the  wish  for  a  reprint.  For  this 
there  is  one  good  reason;  viz.,  that  a  reprint  is 
filed  away  and  becomes  readily  accessible  in  case 
the  physician  wishes  to  refresh  his  mind  on  a 
particular  subject,  whereas  the  journal  in  which 
the  desired  article  appeared  is  usually  displaced 
and  frequently  can  not  be  found  among  the  mass 
of  medical  literature  when  it  is  most  needed. 

Dr.  Stuart  McQuire,  of  Richmond,  Va.,  about 
two  years  ago,  embodied  a  number  of  his  reprints 
in  one  volume.  It  made  a  handy  book.  The  idea 
impressed  me  as  a  splendid  one.  There  have  been 
occasions  when  it  was  my  desire  to  obtain  his 


tO  PREFACE 

opinion  on  some  special  subjects  and  it  was  a  relief 
to  be  able  to  do  so  without  loss  of  time. 

In  presenting  in  brochure  form  my  monograph 
on  the  treatment  of  vascular  tumors  by  the  injec- 
tion of  boiling  water  it  is  the  hope  that  it  may 
perhaps  be  of  a  similar  service  to  the  busy  prac- 
titioner. 

To  the  thoughtful  physician  this  subject  pos- 
sesses points  of  interest  in  which  advantages  can 
readily  be  recognized.  Would  a  physician  remove 
a  vascular  tumor  from  a  baby's  face,  especially 
if  that  baby  be  a  girl,  with  the  scalpel,  when  an- 
other measure  will  completely  obliterate  the  tu- 
mor without  any  scar  or  disfigurement  1  If  so,  an 
excision  under  such  circumstances  would  be  an 
unjustifiable  procedure.  What  excuse  can  the 
physician  offer  for  the  cicatrix  that  has  been  left 
in  place  of  this  tumor?  None,  except  that  he 
was  not  familiar  with,  or  did  not  know  of  the 
existence  of  any  other  method  whereby  this  could 
have  been  accomplished  with  a  happier  result. 

When  Dr.  John  A.  Wyeth  advocated  the  injec- 
tion of  boiling  water  into  these  tumors  as  a  cura- 
tive agent,  I  doubt  very  much  if  he  was  aware  of 
the  greatness  of  his  beneficent  advice.  Many  a 
mother  has  remembered  him  in  her  prayers  for  the 
good  that  has  come  to  her  child  through  his 
method.  When  some  fifteen  years  ago  Dr.  Wyeth 
presented  his  idea  of  injecting  vascular  tumors 
with  water  at  a  high  temperature  at  the  meeting 


PREFACE  11 

of  the  American  Medical  Association,  Dr.  William 
J.  Mayo,  in  the  course  of  his  discussion,  stated  that 
it  was  his  belief  that  the  procedure  was  one  of  the 
advances  in  the  treatment  of  tumors  of  the  blood 
vessels. 

The  farsightedness  of  this  remark  by  this  emi- 
nent surgeon  has  been  fully  realized.  Nothing  can 
be  more  convincing  than  to  see  a  vascular  tumor, 
the  size  of  a  pigeon's  egg7  disappear  about  five 
weeks  after  one  or  two  injections  of  boiling  water, 
and  leave  the  structures  in  a  state  bordering  on 
the  normal. 

For  my  successes  I  am  deeply  indebted  to  Dr. 
Wyeth.  It  has  been  my  good  fortune  to  enjoy  a 
number  of  visits  with  this  master  surgeon  where  I 
could  hear  from  him  in  a  most  interesting  man- 
ner his  views  and  ideas  on  the  treatment  of  these 
vascular  tumors.  During  one  of  my  visits  when 
the  doctor  enlightened  me  with  most  valuable  sug- 
gestions relative  to  this  procedure,  I  asked  him  if 
he  would  be  kind  enough  to  write  a  few  lines  about 
the  treatment  of  vascular  tumors  by  the  injection 
of  water  at  a  high  temperature  in  the  way  of  an 
introduction,  should  I  decide  to  present  the  sub- 
ject in  brochure  form.  To  this  request  he  gave 
me  an  affirmative  reply,  for  which  I  am  very 
grateful. 

Francis  Reder. 

St.  Louis,  Mo. 


ILLUSTRATIONS 

PLATE  PAGE 

I.  Cavernous  angioma  of  left  cheek  and  upper  lip     Frontispiece 

II.  Plexiform    angioma        Facing  28 

FIG. 

1.  Angioma  of  right  cheek  complicated  by  nevus     ....  2(1 

2.  Angioma  of  lower  lip 21 

3.  Angioma  of  lower  lip  in  left  corner  of  mouth     ....  22 

4.  Angioma  of  tip  of  nose  and  underneath  upper  lip     .     .  23 

.").  Angioma  of  left  upper  eyelid 24 

(>.  Angioma  of  left  frontoparietal  region 25 

7.  Angioma  of  right   middle  finger  near  knuckle     ....  26 

„  s.  Angioma  of  left    gluteal    region 27 

!t.  Angioma  of  tongue 34 

Id.  Cavernous   angioma   of   right  cheek  of   congenital   nevoid 

origin 37 

11.  Front  view  of  case  shown   in  Fig.  10 38 

12.  Showing  result  of  Wyeth  treatment  and  paquelinization     .  39 
1  .">.  Front  view  of  case  shown  in  Fig.  12 40 

14.  All-glass  syringe 42 

15.  Jacketed   syringe  and   cork-protected  needle 44 

16.  Operating  room   arrangement 46 

1 7.  Injection  of  boiling  water 47 

IS.  Plexiform   angioma 53 

19.  Showing  the  result  of  "Wveth  treatment  in  case  shown  in 

Fig.   18      .     .     .     .  ' 54 

20.  Angioma  of  left  upper  eyelid 56 

21.  Showing  result  of  Wyeth  treatment  in  case  shown  in  Fig. 

20,    front    view y 57 

22.  Showing  result  of  Wyeth  treatment  in  case  shown  in  Fig. 

20,   lateral   view 58 

23.  Cirsoid    aneurysm 60 

24.  Showing    result    of    Wyeth    treatment    in    case    shown    in 

Fig.  23 61 

25.  Cavernous  angioma  of  left  cheek  and  upper  lip     ....  65 

26.  Showing   result    of   Wyeth    treatment   in    case    shown    in 

Fig.   25 67 

13 


INTRODUCTION 
By  Dr.  John  A.  Wyeth 

While  limited  to  a  comparatively  narrow  field, 
the  value  of  water  at  a  high  temperature  as  a 
therapeutic   agent   has   been   fully   demonstrated. 

It  is  more  than  seventeen  years  since  I  first  em- 
ployed this  method  to  coagulate  subdermally  the 
blood  and  lymph  for  the  arrest  of  the  circulation 
in  arterial,  venous,  capillary,  and  lymphatic  angio- 
mata.  A  certain  proportion  of  these  neoplasms  are 
at  times  inoperable,  either  by  the  ligature  or  by 
excision,  on  account  of  noncontrollable  hemor- 
rhage ;  and  among  the  most  gratifying  experiences 
of  my  career  have  been  the  cure  of  a  very  consider- 
able number  of  cases,  which,  without  this  method 
of  treatment,  must  have  been  hopelessly  aban- 
doned to  untimely  death,  or  to  lifelong  disfigure- 
ment. 

It  is  essentially  applicable  to  the  arrest  and  cure 
by  ultimate  absorption  of  that  form  of  arterial 
angioma  (cirsoid  aneurysm)  which  most  fre- 
quently affects  the  arteries  of  the  scalp,  and  to  the 
large,  venous  angiomata  with  rich  anastomoses, 
which,  while  in  the  majority  of  instances  are  found 
above  the  level  of  the  clavicles,  may  be  met  with 
in  any  part  of  the  body.  So  far,  all  of  these  cases 
have  been  successfully  treated,  and,  to  my  sur- 
prise, without  disaster,  even  from  embolism. 

15 


k; 


INTRODUCTION 


I  am  confident  the  author  of  this  monograph 
will  deal  with  the  technic  in  detail.  The  fact  will 
ever  be  present  in  the  operator's  mind  that  water, 
at  or  above,  212°  F.  is  instantly  destructive  of  the 
skin  in  the  presence  of  the  atmosphere.  Even  sub- 
dermally  a  too  intense  heat  should  not  be  used 
near  the  skin  or  a  vessel,  or  a  vitally  important 
nerve. 


THE    TREATMENT    OF    CAVERNOUS   AND 

PLEXIFORM  ANGIOMATA  BY  THE 

INJECTION  OF  BOILING  WATER 

(WYETH  METHOD) 

An  angioma  is  a  vascular  tumor,  nonmalignant 
in  character.  On  an  anatomic  basis,  angiomata 
can  be  classified  as  venous,  which  are  rather 
frequently  observed;  then  arterial,  or  plexiform 
angioma,  otherwise  known  as  a  cirsoid  aneurysm, 
the  "angioma  arteriale  racemosum"  of  Yirchow, 
a  vascular  neoplasm  rarely  observed,  and,  lastly, 
the  capillary  form,  the  so-called  "port-wine  stain" 
or  "mother's  mark,"  which  is  quite  common. 

The  theory  that  these  neoplasms  are  caused  by 
a  dilatation  of  the  capillaries,  the  walls  of  which 
have  become  absorbed,  resulting  in  the  formation 
of  spores,  has  been  favorably  received.  Of  the 
cavernous  angioma,  it  can  be  said  that  it  is  a 
large,  blood-filled  nonpulsating  cavity,  of  variable 
size,  with  a  thin  covering  of  skin,  usually  bluish 
in  color. 

The  walls  of  these  spaces  possess  an  endothelial 
lining  similar  to  that  of  veins.  Numerous  tortuous 
vessels  supply  the  blood  which  fills  these  cavities 
and  circulates  with  varying  degrees  of  rapidity. 
The  arteries  open  directly  into  the  cavities. 

17 


18  CAVERNOUS   AND    PLEXIFORM    ANGIOMATA 

The  connective  tissue  enmeshing  the  vessels  of 
an  angioma  is  sometimes  scanty  and  sometimes 
plentiful,  thus  causing  irregularities  about  the 
vascular  tumor  that  often  give  it  a  lobulated 
appearance. 

A  venous  angioma  may  be  diffuse,  or  may  form 
a  distinctly  circumscribed  tumor.  A  circum- 
scribed cavernous  angioma  possesses  its  distinct 
efferent  artery  and  afferent  veins  and  does  not 
communicate  with  the  neighboring  capillaries;  i.  e., 
there  exists  no  anastomosis  with  the  capillaries  in 
the  surrounding  tissue.  The  angioma  shows  a  cir- 
culation wholly  within  itself,  there  being  only  a 
connection  with  the  neighboring  arteries  and 
veins. 

Their  growth  is  slow.  They  increase,  how- 
ever, progressively  in  size  with  the  growth  of  the 
patient;  viz.,  a  baby  which  at  three  months  shows 
an  angioma  upon  its  lip  that  has  the  appearance 
of  a  fleabite,  will  exhibit  the  same  lesion  the  size 
of  a  hazelnut  nine  months  later. 

These  vascular  neoplasms  are  congenital  in  their 
origin.  They  are  benignant  in  character  and  al- 
though their  histologic  formation  closely  resem- 
bles certain  types  of  malignancy,  yet  clinically 
angiomata  are  considered  nonmalignant. 

One  of  the  principal  characteristics  of  a  heman- 
gioma is  that  the  entire  tumor  can  be  caused  to 
disappear  upon  pressure,  with  a  prompt  return  to 
its  original  size  as  soon  as  the  pressure  is  removed. 


TREATMENT    WITH    BOILING    WATER  19 

Another  characteristic  is  the  prompt  response 
in  reflecting  the  temperament  of  its  possessor,  ex- 
citable influences  causing  the  tumor  to  swell,  be- 
come tense,  and  more  deeply  discolored.  This  is 
accomplished  through  elastic  fibers,  closely  resem- 
bling the  normal  erectile  tissues  of  the  body,  which 
are  contained  in  the  connective  tissue  stroma. 

From  statistics  it  must  be  inferred  that  the  face 
is  the  favorable  locality  for  an  angioma,  two- 
thirds  of  these  growths  being  located  there. 

The  brow  and  the  cheeks  seem  to  be  selective 
regions.  Next  in  frequency  come  the  lips,  the  nose, 
the  ears,  and  the  eyelids.  Strange  as  it  may  ap- 
pear, the  feminine  sex  is  more  prone  to  this  affec- 
tion than  the  male,  two-thirds  of  all  cases  occur- 
ring in  females. 

Cavernous  angiomata  may  occur  in  the  orbit, 
muscle,  liver,  spleen,  kidneys,  and  the  alimentary 
tract.  These  vascular  tumors  have  also  been  found 
in  bone,  the  ''myelogenous  angioma"  of  Virchow, 
an  extremely  rare  condition.  Its  resemblance  to 
osteosarcoma  is  very  great,  making  an  intra  vitam 
diagnosis  almost  impossible. 

Inasmuch  as  there  is  no  pain  jn  connection  with 
a  cavernous  angioma,  except  when  the  tumor  is 
so  located  as  to  cause  pressure  upon  a  nerve,  the 
discomfort  experienced  must  be  ascribed  to  its 
size  and,  of  course,  its  location.  For  instance,  a 
vascular  tumor  situated  upon  the  upper  eyelid  can 
become  very  annoying  on  account  of  visual  inter- 


20  CAVERNOUS    AND    PLEX1FORM    ANGTOMATA 


Fig.  1. — Baby  G.,  age  eighteen  months.  Angioma  of  right 
cheek,  complicated  with  a  nevus.  Four  injections  obliterated 
the  angioma.  First  injection,  September  10,  1913,  3  ounces; 
second  injection,  October  12,  1913,  3  ounces;  third  injection, 
December  6,  1913,  2  ounces;  fourth  injection,  February  18, 
1914,  2  ounces.  The  tumor  had  entirely  disappeared  by  June 
1,  1914.  The  nevus  was  destroyed  with  two  applications  of  the 
Paquelin  cautery. 


TREATMENT    WITH    BOILING    WATER 


21 


Fig.  2. — Baby  Mv  age  seven  months.  Angioma  of  lower  lip. 
One  injection  of  boiling  water  obliterated  the  angioma.  The 
angioma  was  injected  with  1.5  ounces  January  5,  1914.  There 
was  complete  disappearance  of  the  tumor  by  April  1,  1911. 


22  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 


Fig.  3. — Baby  C,  age  two  years.  Angioma  of  lower  lip  in  left 
corner  of  mouth.  When  baby  laughed  this  tumor  would  roll 
out  of  the  corner  of  the  mouth  and  appear  as  large  as  a  Cali- 
fornia grape,  dark  purple  in  color.  Three  injections  obliterated 
the  tumor.  First  injection,  April  6,  1914,  0.5  ounce.  Second 
injection,  June  3,  1914,  0.5  ounce.  Third  injection,  October 
11,  1914,  0.5  ounce. 


TREATMENT    WITH    BOILING    WATER 


23 


Fig.  4. — Peter  E.,  age  nineteen  years.  Angioma  on  tip  of 
nose  and  underneath  upper  lip.  Two  injections  required  for 
tumor  underneath  the  upper  lip,  and  three  injections  for  angioma 
on  tip  of  nose.  Owing  to  the  cartilaginous  structure  of  the  tip 
of  the  nose,  much  difficulty  was  experienced  in  making  these 
injections.  First  injection,  June  2,  1911;  nose,  0.5  ounce,  lip, 
1  ounce.  Second  injection,  July  8,  1911;  nose,  0.5  ounce,  lip,  1 
ounce.  Third  injection,  September  2,  1911;  nose,  0.5  ounce. 
Complete  disappearance  by  October  1,  1911. 


24  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 


Fig.  5. — Baby  E.,  age  three  years.  Angioma  involving  left 
upper  eyelid.  This  tumor  grew  rapidly  during  the  last  four 
months  and  interfered  with  vision.  Two  injections  obliterated 
angioma.  First  injection,  January  3,  1912,  2  ounces.  Second 
injection,  March  1,  1912,  1  ounce.  Disappearance  of  tumor  by 
July  1,  1912. 


TREATMENT    WITH    BOILING    WATER 


25 


Fig.  (3. — Baby  K.,  age  eighteen  months.  Angioma  in  left 
frontoparietal  region.  Two  injections  obliterated  the  angioma. 
First  injection.  May  2,  1914,  about  2.5  ounces.  Second  injection, 
May  28,  1914,  about  1.5  ounces.  Disappearance  of  the  tumor  by 
August  1,  1914. 


2(3 


CAYHUNOUS    AND    PLEXIFORM    ANGTOMATA 


Fig.  7. — John  F.,  are  thirty-two  years.  Angioma  of  right 
middle  finger  near  knuckle.  One  injection  of  2  ounces  caused 
the  tumor  to  disappear  in  six  weeks. 


TREATMENT    WITH    BOILIXU    WATER 


L'< 


Fig.  8. — Frank  L.,  age  forty  years.  Angioma  of  left  gluteal 
region.  Five  injections  required  to  obliterate  this  tumor.  First 
injection,  February  4,  1910,  about  5  ounces.  Second  injection, 
March  <i,  1910,  about  5  ounces.  Third  injection,  May  2,  1910, 
about  3  ounces.  Fourth  injection,  June  18,  1910,  about  3  ounces. 
Fifth  injection,  August  2,  1910,  about  2  ounces.  Complete  dis- 
appearance of  tumor  by  November  1,  1910. 


28  CAVERNOUS   AND   PLEXIFORM   ANGIOMATA 

ference.  Again,  an  angioma  of  the  cheek  may  in- 
volve the  buccal  tissue  to  such  an  extent  as  to  make 
mastication  difficult  and  even  dangerous.  This 
was  exemplified  in  one  of  my  cases  in  which  the 
patient  accidentally  bit  the  inner  side  of  her  cheek, 
causing  an  alarming  hemorrhage. 

Now,  let  us  consider  briefly  the  plexiform  an- 
gioma. This  is  usually  a  distinctly  outlined  tumor 
occurring  in  definite  arterial  regions.  According 
to  Fischer,  12  per  cent  are  of  traumatic  origin,  the 
remaining  88  per  cent  being  derived  from  simple 
congenital  angioma. 

The  tumor  is  composed  of  arteries  and  veins,  the 
tortuous  vessels  giving  this  tumor  mass  a  most 
characteristic  appearance. 

A  favored  site  is  upon  the  forehead,  scalp,  and 
face.  It  is  not  infrequent,  however,  to  find  the 
hand,  fingers,  and  forearm  affected. 

In  its  clinical  characteristics  a  plexiform  an- 
gioma differs  markedly  from  the  cavernous  type. 
The  former  usually  forms  a  flattened  tumor,  grad- 
ually spreading  into  the  surrounding  tissues.  The 
skin  covering  the  tumor  is  very  thin,  usually  more 
of  a  reddish  than  a  bluish  color,  and  is  locally 
adherent.  Pressure  upon  the  mass  will  not  cause 
it  to  be  completely  evacuated,  as  is  the  case  in  a 
cavernous  angioma.  This  must  be  attributed  to 
the  large  number  of  anastomoses. 

Another  characteristic  phenomenon  found  in  the 
plexiform  angioma  and  not  present  in  the  cav- 


Plate  II. 


A  typical  cirsoid   aneurysm    (plexiform   angioma)    of  the   forehead,   a  favorite 
site  for  these  vascular  tumors. 


TREATMENT    WITH    BOILING    WATER  29 

ernous  variety  is  the  well-marked  pulsation  and 
bruit.  For  instance,  the  hand  flatly  applied  to  a 
plexiform  angioma  will  distinctly  perceive  the  pul- 
sation and  bruit  in  the  tumor.  Such  an  angioma 
located  on  the  scalp  or  forehead  will  often  cause 
a  partial  destruction  of  the  underlying  bone  by 
attrition.  This  defect  can  be  readily  discovered 
by  making  gentle,  but  firm  pressure  upon  the  thin- 
ned-out  skin  of  the  tumor,  at  the  same  time  sweep- 
ing the  finger  over  the  affected  area. 

A  plexiform  angioma  is  not  free  from  clinical 
symptoms ;  it  usually  causes  dizziness,  vertigo,  and 
a  dull  pain  in  the  head.  Such  disturbances  are  not 
associated  with  a  cavernous  angioma. 

The  capillary  form  of  angioma  has  very  little 
of  clinical  significance,  and  exclusive  of  the  un- 
sightly appearance,  causes  no  discomfort.  It  is 
not  often  that  the  possessor  of  a  port-wine  stain 
seeks  advice  as  to  the  possibility  of  having  it  re- 
moved. Even  so,  should  the  angioma  involve  a 
large  area,  which  they  not  infrequently  do,  noth- 
ing of  an  encouraging  nature  as  to  its  total  or  even 
partial  removal  could  be  promised. 

An  interesting  fact  in  connection  with  capillary 
angioma  is  that  their  distribution  often  corre- 
sponds to  the  area  of  distribution  of  the  three 
branches  of  the  fifth  cranial  nerve;  viz.,  angioma 
of  the  frontal  germinal  area,  and  angioma  of  the 
superior  and  inferior  maxillary  areas.  Baren- 
sprung  was  the  first  to  call  attention  to  this.  Cush- 


30  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

Lng  and  others  later  confirmed  his  observations. 
Simon  entertained  a  theory  that  nutritive  dis- 
turbances in  the  region  of  the  trigeminus  were 
causal  in  producing  such  a  condition.* 

Virchow  advanced  a  theory  that  angiomata 
find  their  origin  in  the  embryonic  relations  when 
slight  irritative  conditions  about  the  margins  and 
the  circumference  of  the  fetal  clefts,  which  are 
always  copiously  supplied  with  blood  vessels,  may 
cause  an  abnormal  development  about  these  parts, 
with  the  possibility  of  a  nevus  formation.  Such 
a  condition  may  remain  latent  for  a  time  and  later 
manifest  itself  as  a  cavernous  angioma.  Virchow 
lias  applied  to  them  the  name  of  "angioma  fissu- 
raux. ' ' 

According  to  Ribbert,  the  genesis  of  angiomata 
rests  with  two  questions:  Is  the  tumor  a  sim- 
ple dilatation  of  the  vessels  in  a  circumscribed 
area!  or,  is  the  tumor  the  result  of  a  new  growth? 
To  this  may  be  added  Stangl's  argument  as  to 
whether  or  not  these  vascular  tumors  are  of 
epithelial  or  connective  tissue  extraction.  Ribbert 
advocates  the  view  that  they  are  the  result  of  a 
new  growth.  From  the  exhaustive  researches  that 
this  interesting  vascular  lesion  has  been  sub- 
jected to,  the  inference  must  be  made  that  the 
genesis  of  angiomata  is  not  clearly  understood. 


*%arry  in  his  interesting  exposition  of  this  lesion  adheres  to  a  theory 
that  angiomata  are  congenital  vascular  productions  caused  by  modifica- 
tions occurring   during  embryonal   development. 


TREATMENT    WITH    BOILING    WATER  31 

A  cavernous  or  plexiform  angioma,  especially 
of  large  size,  is  one  of  the  most  difficult  lesions 
with  which  the  surgeon  has  to  contend.  In  fact, 
some  of  these  lesions  are  looked  upon  as  inoper- 
able and  have  been  abandoned  to  an  ever- 
increasing  deformity  and  discomfort. 

The  most  radical  intervention  for  the  "cure" 
of  an  angioma  is  excision.  However,  before  hav- 
ing recourse  to  this  measure,  it  is  well  to  consider 
several  salient  points.  One,  a  point  of  much  im- 
port, is  the  size  and  location  of  the  angioma,  and 
the  risk  to  life  from  hemorrhage.  Another  point, 
and  one  that  commands  recognition,  especially 
when  the  angioma  is  located  on  the  face,  is  the 
liability  to  deformity  from  mutilation  and  cica- 
trization. 

These  two  points  can  be  fused  into  one  consid- 
eration for  the  surgeon  who  attempts  to  cure  an 
angioma  by  excision;  viz.,  that  this  radical  measure 
is  only  permissible  when  the  vascular  tumor  is  of 
limited  extent,  well-circumscribed,  and  situated  in 
parts  which  can  be  sacrificed  without  the  danger 
of  great  hemorrhage  or  the  loss  of  important 
structures.  » 

In  an  angioma  of  the  face,  the  effect  of  a  muti- 
lating or  disfiguring  operation  must  be  seriously 
considered,  especially  in  the  female  sex. 

That  many  of  these  tumors  are  inoperable;  i.  e., 
not   amenable   to   extirpation,   has   been   demon- 


32  CAVERNOUS   AND   PLEXIFOTIM   ANGTOMATA 

strated  repeatedly  by  an  attempted  operative 
measure  which  had  to  be  abandoned. 

Other  surgical  measures,  such  as  peripheral  li- 
gation, ligature  of  the  afferent  arteries,  and  tissue 
strangulation  by  the  buried  ligature,  have  been 
considered  when  a  surgical  extirpation  seemed  too 
hazardous.  However,  the  results  have  at  best  been 
only  palliative  and  disappointing. 

The  severity  of  the  surgical  intervention  in  deal- 
ing with  an  angioma  caused  other  methods  to  be 
promulgated.  Efforts  were  made  to  destroy  the 
growth  with  all  its  constituent  elements  by  the  in- 
terstitial action  of  irritating  caustics  or  other 
agents  applied  externally  or  introduced  into  the 
afflicted  tissues.  Some  of  these  methods  have  been 
used  by  me,  but  have  proved  disappointing. 

For  instance,  the  injection  of  alcohol  (Schwalbe) 
and  ferric  sesquichloride  are  very  prone  to  cause 
suppuration,  and  are  not  to  be  recommended.  In- 
jection of  hydrogen  peroxide  (Mosetig-Moorhof) 
is  a  dangerous  agent  to  use.  Its  introduction  may 
be  followed  by  a  fatal  gas  embolism  in  the  lungs. 
Payr's  method,  consisting  of  the  introduction  into 
the  tumor  of  darts  or  rods  of  magnesium,  a  pro- 
cedure that  does  not  involve  the  danger  of  throm- 
bosis or  embolism,  is  not  familiar  to  me,  neither 
have  I  had  any  experience  with  radium. 

The  injection  of  water  at  the  boiling  point  as 
recommended  by  Dr.  John  A.  Wyeth  has  given  me 
the  most  satisfactory  results.     The  method  must 


TREATMENT    WITH     BOILING    WATER  33 

be  looked  upon  as  one  of  the  advances  in  the 
treatment  of  vascular  tumors.  Of  104  cases  sub- 
jected to  this  method,  1  have  had  no  failures  to 
record.  The  results  were  certain,  and  the  pro- 
cedure was  free  from  accident.  There  are  two 
cases,  however,  of  which  I  wish  to  briefly  speak. 

In  the  first  case,  a  child  of  sixteen  months,  with 
an  angioma  on  the  lower  lip  to  the  left  of  the 
midline,  in  size  as  large  as  a  filbert,  had  received 
two  injections  in  the  course  of  six  weeks.  The 
tumor  was  reduced  to  slightly  less  than  half  its 
size.  It  was  then  quite  hard  and  its  color,  which 
before  the  injection,  was  purple,  was  that  of  the 
normal  lip. 

The  mother  became  dissatisfied  that  the  tumor 
had  not  entirely  disappeared.  At  the  advice  of 
her  friends,  she  saw  a  physician  who  removed  it 
by  excision.  The  removal  was  a  success,  and 
were  it  not  for  the  scar  on  the  lip  the  result  would 
have  been  ideal. 

I  was  informed  by  the  physician  that  the  re- 
moval was  attended  with  but  little  bleeding.  This 
must  be  explained  on  the  assumption  that  the 
blood  in  the  tumor,  coagulated  by  the  boiling 
water,  had  become  well  organized.  The  mouths 
of  the  vessels  opening  into  the  vascular  tumor  had 
been  well  sealed.  It  was  noticed  during  the  sec- 
ond injection  that  the  boiling  water  did  not  enter 
the  vascular  growth  so  easily  as  during  the  first. 
More  piston  pressure  was  necessary,  and  the  dif- 


34  CAVERNOUS   AND   PLEXIFORM   ANGIOMATA 


Fig.  9. — Albert  H.,  a<je  forty  years.  Angioma  of  tongue. 
Tumor  was  size  of  an  ordinary  pecan  and  was  located  midway 
nn  the  right  marginal  side.  A  little  less  than  an  ounce  of  boil- 
ing water  was  injected.  The  resultant  edema  spread  to  the 
epiglottis  and  so  embarrassed  breathing  that  six  hours  after 
the  injection  it  became  advisable  to  perform  laryngotomy. 
Thirty-six  hours  later  the  edema  had  subsided  and  breathing 
became  normal.  The  tube  was  then  removed.  Patient  made  a 
prompt  recovery.  Angioma  had  entirely  disappeared  eight 
weeks  later. 

This  distressing  condition  could  have  been  avoided  if  a 
smaller  dosage  of  boiling  water  had  been  injected  and  repeated 
to  meet  conditions  later  as  they  presented  themselves.  This 
was  demonstrated  in  two  subsequent  cases  when  an  extensive 
edema  was  anticipated  by  resorting  to  small  quantities  of  boil- 
ing water  and  repeating  the  injection. 


TREATMENT    WITH    BOILING    WATER  35 

ficulty  was  plainly  apparent.  This  was  noticeable 
in  every  angioma  of  the  lip  that  required  subse- 
quent boiling-water  injection. 

The  structure  of  the  lip  is  peculiar  in  its  make- 
up, and  it  is  advisable  to  use  extra  precautions 
while  introducing  boiling  water  into  these  struc- 
tures. It  is  far  better  to  subject  the  tumor  to  a 
subsequent  injection,  rather  than  have  an  overdis- 
tention  during  the  first  injection  that  may  be  the 
cause  of  a  slough.  The  greatest  success  in  a  lip 
angioma,  however,  can  be  obtained  by  introduc- 
ing the  proper  quantity  of  boiling  water  at  the 
first  injection.  Otherwise,  conditions  may  arise, 
as  those  just  cited,  which  may  invite  excision. 

It  is  gratifying,  however,  to  know  that  an  an- 
gioma of  the  lip  which  had  not  been  entirely 
obliterated  by  the  injection  of  boiling  water  can 
be  excised  with  very  little  loss  of  blood. 

The  other  case  was  that  of  a  young  man  who  had 
an  angioma  midway  on  the  right  margin  of  his 
tongue.  The  growth  was  as  large  as  a  pecan  nut 
and  deep  purple.  Xot  quite  an  ounce  of  boiling- 
water  was  introduced  into  it.  Within  six  hours 
the  edema  had  involved  the  epiglottis  to  such  an 
extent  that  breathing  was  seriously  embarrassed. 
It  was  necessary  to  perform  a  laryngotomy.  In 
thirty-six  hours  the  edema  had  subsided  and 
breathing  again  became  normal.  The  angioma  dis- 
appeared entirely  in  eight  weeks. 

In  this  case  too  much  boiling  water  had  been 


36  CAVERNOUS    AND    PLEXIFOKM    ANGIOMATA 

injected  at  once,  it  would  have  been  safer  to  have 
given  a  smaller  amount,  repeating  the  injection  in 
three  or  four  weeks,  if  necessary. 

The  question,  whether  or  not  a  cavernous  or  a 
plexiform  angioma  is  a  lesion  that  endangers  life, 
must  be  answered  in  a  guarded  manner.  These 
vascular  tumors  possess  an  element  of  danger  in 
proportion  to  their  size  and  location.  When  there 
is  noninterference,  their  growth  may  eventually 
produce  a  secondary  lesion  by  spreading  indefi- 
nitely, which  may  cause  death.  When  there  is 
operative  intervention,  that  is,  excision,  the  great 
danger  is  hemorrhage. 

The  injection  of  boiling  water  is  not  entirely 
free  from  danger.  However,  of  all  the  procedures 
it  is  unquestionably  the  safest.  The  danger  of  an 
embolism  must  be  reckoned  with,  and  in  all  injec- 
tions peripheral  compression  while  the  boiling- 
water  is  being  introduced  into  the  tumor  must  be 
made. 

There  is  always  a  possibility  that  boiling  water 
injected  into  a  plexiform  (cirsoid  aneurysm),  lo- 
cated upon  the  head,  might  be  productive  of  a 
meningeal  trouble.  Furthermore,  it  may  be  read- 
ily seen  how  a  slough  can  result  from  boiling 
water  when  injected  into  a  cavity  filled  with 
blood.  It  is  not  a  simple  matter  to  judge  a  boil- 
ing water  injection. 

Before  speaking  of  the  technic  of  the  boiling- 
water  injection,  I  wish  to  say  something  about  a 


TREATMENT    WITH    BOILING    WATER 


;;< 


Fig.  10. — Xeoma  K.,  age  five  years.  Cavernous  angioma  of 
lace  of  congenital  nevoid  origin.  Two  injections  of  2  ounces 
and  iy2  ounces  respectively  covering  a  period  of  six  weeks 
completely  obliterated  the  angioma.  The  nevus  was  destroyed 
with  the  pointed  Paquelin  cautery.  Three  applications  at  inter- 
vals of  four  weeks  were  necessary  to  efface  this  obstinate  vas- 
cular growth. 


38  CAVERNOUS   AND   PLEXIFORM   ANGIOMATA 


Fig.    11. — Xeoma    K.,    age   five    years.     Front    view    of    case 
shown  in  Fie.'.  10. 


TREATMENT    WITH    BOILING    WATER 


39 


Fig.  12. — Neoma  K.,  age  five  years.  The  slight  shading 
about  the  malar  region  depicts  the  site  of  the  nevus  and  the 
result  of  paquelinization. 


41) 


CAVERNOUS    AND    PLKXIKORM    ANGIOMATA 


Fig.  13. — Neoma  K.,  age  five  years, 
of  ease  shown  in  Figs.  10,  11,  and  12. 


Result  after  treatment 


TREATMENT    WITH    BOILING    WATEE  41 

type  of  nevus  which  is  elevated  above  the  skin, 
and  has  been  of  interest  to  me.  It  is  not  infre- 
quent that  a  nevus  complicates  an  angioma.  The 
treatment  of  a  nevus  has  proved  more  or  less  un- 
satisfactory to  me,  no  matter  what  method  I  em- 
ployed. The  Paquelin  cautery  with  round  point 
has  given  the  best  results,  yet  that  was  not  satis- 
factory because  recurrences  were  numerous,  re- 
quiring frequent  applications  of  the  cautery.  This 
procedure  usually  resulted  in  a  well-defined  scar, 
which  was  very  undesirable. 

By  using  the  boiling-water  injection  in  conjunc- 
tion with  the  cautery,  I  found  that  usually  with 
one  application  of  the  cautery  a  satisfactory  ob- 
literation of  the  nevus  could  be  accomplished. 
This  is  to  be  explained  on  the  ground  that  the 
nevus  is  feci  by  deeper  lying  vessels,  even  in  the 
absence  of  an  angioma.  The  injection  of  boiling- 
water  introduced  underneath  the  skin  in  the  con- 
nective tissue  in  the  immediate  vicinity  of  the 
nevus  will  obliterate  these  vessels,  thus  depriving 
the  nevus  of  further  nourishment.  The  cautery, 
with  the  aid  of  this  starvation,  will  usually  prove 
successful  with  one  application. 

In  making  the  injection  of  boiling  water  into  an 
angioma  certain  conveniences  will  expedite  this 
measure.  A  suitable  syringe  is  essential.  I  have 
found  that  an  all-glass  syringe  with  a  good  shoul- 
der, a  large  ring  on  the  piston,  and  an  asbestos 


42  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 


Fig.  14. — All-glass  syringe,  small  size,  for  injecting  boiling 
wilier  into  an  angioma.  Note  the  asbestos  plunger,  the  large 
ring  at  the  end  of  the  piston,  the  shoulder  of  the  barrel,  and 
the  point  of  the  barrel  which  is  ground  to  receive  the  "slip" 
needle.  A  syringe  with  a  capacity  of  one  or  two  ounces  is  the 
preferable  syringe  for  boiling  water  injections. 


TREATMENT    WITH    BOILIXG    WATER  43 

plunger,  has  answered  the  purpose  better  than 
any  of  the  many  I  have  tried. 

A  syringe  with  an  all-glass  plunger  has  its  draw- 
backs, as  the  steam  generated  within  the  barrel 
will  find  its  way  between  it  and  the  glass  plunger, 
thus  inhibiting  the  free  and  easy  movement  of  the 
piston,  so  essential  to  this  procedure. 

The  slip  needle  (small  caliber,  Xo.  20)  is  the 
preferable  one.  With  it  no  time  is  being  lost  in 
the  transference  of  the  boiling  water.  It  should 
always  be  borne  in  mind  that  the  water  must  be 
injected  at  a  boiling  temperature  and  time  is  an 
important  factor.  It  can  be  stated  that  those  cases 
of  angiomata  subjected  to  the  boiling-water  treat- 
ment which  did  not  respond  properly,  did  not  re- 
ceive the  "water"  hot  enough. 

To  protect  the  hands,  at  the  same  time  making- 
it  possible  to  handle  the  boiling  water,  a  pair  of 
easy-fitting  chamoisette  gloves  of  good  thickness 
have  served  me  well.  That  portion  of  the  glove 
intended  for  the  little  finger  is  cut  off,  so  that  the 
degree  of  heat  in  the  tissues  can  be  judged  by 
occasional  contact  with  the  exposed  end  of  the 
finger.  * 

Another  protection  for  the  hands  of  the  opera- 
tor, while  transferring  the  boiling  water,  and  one 
which  has  been  found  very  valuable  because  it 
does  not  require  the  wearing  of  gloves,  was  con- 
trived by  jacketing  the  barrel  of  the  syringe  with 
a  heavy  piece  of  white  rubber  tubing.    The  tubing 


44  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 


Fig.  15. — Showing  how  the  barrel  of  the  syringe  is  jacketed 
with  a  piece  of  white  rubber  tubing.  The  "window"  in  the 
jacket  is  placed  so  that,  should  the  boiling  water  be  drawn  be- 
yond the  edge  of  the  tube,  it  can  be  seen  and  its  expulsion  con- 
trolled. Note  the  "shoulder"  of  the  needle  imbedded  in  a 
cork,  so  that  the  transmitted  heat  from  the  boiling  water  will 
not  burn  the  unprotected  finger  steadying  the  needle. 


TREATMENT    WITH    BOILING    WATER  45 

does  not  cover  the  barrel  to  its  full  length,  as 
this  is  not  necessary  with  the  syringe  that  is  gen- 
erally used.  It  permits  the  exposure  of  the  lower 
half,  and  inasmuch  as  the  syringe  is  never  drawn 
full  of  boiling  water  when  an  injection  is  made,  it 
is  an  advantage  in  being  able  to  watch  the  amount 
of  water  that  is  being  forced  out. 

To  furthermore  facilitate  observation  in  case 
the  boiling  water  is  drawn  beyond  the  edge  of  the 
rubber  jacket,  a  "window"  is  cut  into  the  lower 
half  of  the  tube. 

To  protect  the  fingers  of  the  hand  engaged  in 
steadying  the  needle  from  the  heat  that  will  be 
transmitted  to  the  needle,  a  cork  placed  about  the 
"shoulder"  of  the  needle  has  been  found  very 
efficacious. 

This  method  of  protection  has  the  advantage 
of  having  the  hands  unincumbered  with  gloves. 

The  arrangement  in  the  operating  room  should 
be  such  that  the  surgeon  stands  between  the  ves- 
sel containing  the  boiling  water  (the  water  being- 
kept  constantly  at  the  boiling  point  over  a  flame), 
and  the  patient,  at  a  distance  that  will  not  neces- 
sitate a  step  on  the  part  of  the  surgeon  for  the 
transference  of  the  boiling  water  into  the  tumor. 

The  parts  not  involved  should  be  protected  with 
moist  cloths,  lest  a  scalding  of  these  tissues  result 
from  the  hot  water  in  the  syringe  being  forced  out 
at  the  needle  junction  by  the  generated  steam. 

The  introduction  of  the  needle  and  the  force 


46  CAVERNOUS    AND   PLEXIFORM   ANGIOMATA 


Fig.  16. — Showing  position  of  surgeon  and  patient  for  an 
injection  of  boiling  water.  Note  the  distance  between  surgeon 
and  patient  and  the  open  vessel  containing  the  water  at  boiling 
point  over  a  flame.  The  movement  on  the  part  of  the  surgeon 
in  transferring  the  boiling  water  is  barely  a  quarter  of  a  circle. 
The  canula  is  previously  introduced  into  the  region  where  the 
injection  is  to  be  made.  It  requires  only  a  second  to  make 
connection  with  the  syringe. 


TREATMENT    WITH    BOILING    WATER 


47 


Fig.   17. — Showing   how   the  boiling  water  is  being  injected 
into  an  angioma. 


48  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

applied  in  injecting'  the  hot  water  is  of  much  im- 
portance. Inasmuch  as  the  tissues  of  the  new 
growth  do  not  offer  the  resistance  of  normal  skin, 
the  hot  water  injected  without  great  care  may 
cause  these  tissues  to  break  down.  Injections 
made  directly  into  the  soft  vascular  mass  are  in- 
variably followed  by  a  necrosis. 

For  this  reason,  it  is  well  to  make  the  initial 
injections  by  introducing  the  needle-  through  the 
sound  skin  about  one-sixteenth  or  one-eighth  inch 
from  the  edge  of  the  angioma  well  into  the  base  of 
the  vascular  tumor,  thus  assuring  coagulation  of 
the  deeper  parent  vessels.  This  is  also  a  wise 
precaution  against  the  dangers  of  embolism. 

If  the  arteries  leading  into  the  tumor  can  be 
demonstrated,  it  is  well  to  enter  the  needle  along 
their  course  and  inject  a  sufficient  amount  of  boil- 
ing water  to  cause  coagulation  in  these  vessels. 

Judgment  should  be  exercised  in  introducing  the 
needle  to  prevent  the  point  from  resting  too  near 
the  opposite  wall  of  the  tumor.  To  properly  esti- 
mate this  procedure,  it  is  well  to  first  introduce 
the  needle  without  the  syringe,  pushing  it  through 
the  mass  till  it  can  be  felt  on  the  opposite  side, 
then  withdraw  to  the  extent  of  half  an  inch.  This 
will  give  a  reasonable  assurance  that  the  boiling 
water  can  be  injected  into  the  tumor  without  the 
likelihood  of  getting  a  slough.  When  the  skin  be- 
gins to  show  signs  of  becoming  blanched  and  turns 
grayish  in  color,  the  injection  into  that  area  is  to 


TREATMENT    WITH    BOILING    WATER  49 

be  discontinued.  Hyperdistention  must  be  care- 
fully guarded  against.  The  amount  of  hot  water 
necessary  to  cause  this  bleaching  rests  wholly 
with  the  amount  of  tissue  under  treatment.  After 
coagulation  of  this  particular  area  has  been  satis- 
factorily accomplished,  the  point  of  the  needle  is 
made  to  penetrate  into  another  area  of  the  tumor 
and  the  hot  water  injected. 

In  this  manner  the  needle  is  introduced  into  the 
tumor  in  different  places,  and  at  various  angles, 
(ill  the  whole  mass  gives  evidence  of  coagulation. 

The  quantity  of  hot  water  which  may  be  in- 
jected at  one  sitting  can  amount  to  three  or  four 
ounces  in  a  tumor  the  size  of  a  lien's  egg,  the  time 
consumed  in  making  the  injection  being  about 
three  minutes. 

However,  if  the  new  growth  is  of  unusual  size,  it 
would  be  advisable  to  inject  only  a  portion  of  the 
tumor  at  one  time,  making  a  subsequent  injection 
two  or  three  weeks  later. 

It  may  be  stated  here  that  safeguarding  not  only 
becomes  an  imperative  measure  when  tumors  of  an 
unusual  size  are  to  be  injected.  Even  tumors  of 
small  size  when  located  upon  the  tip  of  the  nose, 
upon  the  eyelid,  or  upon  the  tongue,  must  be  ap- 
proached with  great  caution.  A  boiling  water  in- 
jection of  an  angioma  involving  the  tip  of  the 
nose,  if  injudiciously  given,  might  cause  a  necrosis 
of  the  nasal  cartilages,  a  very  distressing  acci- 
dent, should  it  occur.     An  injection  into  an  angi- 


")()  CAVERNOUS   AND    PLEXIFORM    ANGTOMATA 

oma  upon  the  upper  eyelid  must  be  administered 
most  cautiously  on  account  of  the  damage  which 
might  be  inflicted  upon  the  eye;  while  an  angioma 
of  the  tongue,  when  injected  with  too  copiously  a 
dose  of  boiling  water,  may  cause  the  edema  to 
involve  the  epiglottis  and  seriously  embarrass 
respiration.  It  was  my  misfortune  to  meet  with 
such  a  mishap  (see  case  history). 

Boiling  water  injections  into  an  angioma  situ- 
ated in  these  regions  must  be  given  with  good 
judgment  plus  great  care. 

It  is  interesting  to  observe  the  characteristics 
presented  by  an  angioma  subjected  to  the  hot 
water  treatment.  The  independence  of  the  blood 
spaces  from  the  blood  vessels  of  the  surrounding 
tissue  can  be  demonstrated  by  the  fact  that  the 
neighboring  tissue  is  not  affected;  i.  e.,  none  of  the 
hot  water  finds  its  way  into  the  adjacent  struc- 
tures while  the  injection  is  being  made.  However, 
shortly  after  the  injection  an  edema  of  the  im- 
mediate parts  begins  to  manifest  itself.  This 
edema  may  be  very  extensive,  according  to  the 
amount  of  hot  water  injected.  Frequently,  when 
the  lesion  is  on  the  face,  the  swelling  may  become 
so  extensive  as  to  close  the  eyes. 

Although  the  condition  looks  alarming,  there  is 
little  ground  for  actual  fear,  except  when  an  in- 
jection is  made  for  an  angioma  on  the  tongue. 
The  patient  suffers  no  pain,  the  condition  is  an 


TREATMENT    WITH    BOILING    WATER  ol 

afebrile  one,  and  the  edema  usually  subsides  within 
the  first  week. 

It  is  a  wise  precaution  to  apply  ice  or  cold  com- 
presses to  the  tumor  and  surrounding  tissues  im- 
mediately after  the  injection  for  the  first  four  to 
six  hours,  thereby  lessening  the  severity  of  the 
edema. 

At  the  end  of  the  first  week  the  tumor,  but 
slightly  diminished,  has  almost  fully  lost  its  patho- 
logic color  and  the  tissues  are  beginning  to  as- 
sume a  normal  appearance. 

To  the  touch,  the  mass  is  hard.  If  it  remains 
bard,  the  metamorphic  process  is  active  and  no 
further  injection  will  be  necessary.  Should  the 
tumor,  however,  begin  to  show  evidence  of  soften- 
ing with  visible  formation  of  a  new  blood  supply, 
an  immediate  injection  is  indicated.* 
•  The  course  of  an  angioma  successfully  injected 
is  one  of  gradual  diminution,  the  greatest  progress 
being  made  from  the  second  to  the  third  week.  A 
tumor  the  size  of  a  hen's  egg  will  usually  require 
six  to  eight  weeks  for  its  disappearance.  If  the 
injection  has  been  a  fortunate  one,  i.  e.,  free  from 
accident,  such  as  cicatrization*  following  slough- 
ing, the  site  that  once  harbored  the  angioma  will 
appear  healthy  and  quite  normal. 

It  is  advisable  that  a  general  anesthetic  be  ad- 


*A  successful  obliteration  can  only  be  accomplished  by  granular 
metamorphosis,  made  possible  by  the  coagulation  of  the  blood  and  albu- 
minoids; i.  e.,  the  effect  of  the  boiling  water  in  the  tissues  is  to  speedily 
bring  about'  vascular  blockade,  lymph  infiltration,  and  cell  retrograde, 
followed    by   restoration    to    healthy    conditions. 


52  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

ministered.  The  assurance  of  greater  accuracy  in 
administering  the  injection  is  thereby  given. 
Sometimes,  however,  a  general  anesthetic  may 
carry  with  it  elements  of  danger,  as  has  been  the 
case  in  a  cirsoid  aneurysm,  when  the  anesthetic 
had  to  be  discontinued  for  fear  of  bursting  the 
tumor.  I  have  repeatedly  given  the  injection 
without  an  anesthetic  and  was  astonished  that  the 
pain  was  not  more  severe. 

A  Case  of  Plexiform  Angioma 
(Cirsoid  Aneurysm) 

(See  Figs.  18  and  19.) 

J.  W.,  age  forty-three,  a  carpenter,  struck  the 
frontal  portion  of  his  head  against  a  joist  six 
years  ago.  Two  years  later  he  noticed  a  swelling 
in  his  forehead  which  gradually  became  larger, 
spreading  beyond  the  hair  margin  onto  the  scalp. 
During  the  last  six  months,  he  suffered  much  with 
dizziness  and  noises  in  his  head. 

Examination  revealed  a  tumor  mass  involving 
the  frontal  region  back  to  the  coronal  suture. 
Laterally  the  swelling  extended  to  the  temporal 
ridge.  The  tumor  mass  was  evenly  distributed.  A 
hand  placed  flat  upon  the  forehead  would  give  a 
good  idea  of  its  size. 

The  tumor  was  bluish  in  color  and  the  undula- 
tions of  its  surface  gave  it  a  convoluted  appear- 
ance.   All  vessels  leading  to  it  were  tortuous  and 


TREATMENT    WITH    BOILING    WATER  Od 

filled  to  such  an  extent  as  to  make  them  appear 
abnormally  large.  Distinct  pulsations  in  the  vas- 
cular tumor  were  perceptible  and  a  marked 
aneurysmal  bruit  and  fremitus  were  present. 

There  was  considerable  destruction  by  attrition 
of  the  outer  table  of  the  skull. 


Pig.  18. — J.  W.,  age  forty-three  years.  Plexiform  angioma 
(cirsoid  aneurysm)  of  forehead.  Injected  with  five  ounces  of 
boiling  water  at  one  sitting.  Seven  weeks  later  the  tumor  had 
disappeared. 

On  August  10,  1917,  under  a  general  anesthetic, 
this  tumor  mass  was  injected  with  five  ounces  of 
boiling  water.     As  soon  as  the  water  was  intro- 


54 


CAVERXOIS    AXI)    PLEXIFOIt.M     AXGIOMATA 


duced  into  the  cavity  of  the  tumor,  pulsation 
ceased.  The  doughy  feeling  of  the  mass  gave  evi- 
dence of  thorough  coagulation  of  the  blood. 

An  edema  began  to  develop  immediately.     In 
two  days  it  had  reached  its  height.     It  involved 


Fig.  19. — J.  W.  Plexiform  angioma  (cirsoid  aneurysm). 
Appearance  of  patient  shown  in  Fig.  18,  two  months  after 
injection. 


the  upper  half  of  the  face,  closing  both  eyes.  After 
the  third  day,  the  edema  subsided  rapidly,  and 
the  patient  was  able  to  leave  the  hospital  on  the 
fifth  day. 


TREATMENT    WITH    BOILING    WATER  00 

Seven  weeks  later,  all  evidence  of  the  cirsoid 
aneurysm  had  disappeared.  There  was  only  a 
slight  thickening-  discernible  at  its  former  site 
and  that  was  undoubtedly  due  to  an  infiltrated 
periosteum.  The  dizziness  and  noises  in  the  head 
had  disappeared. 

A  Case  of  Cavernous  Angioma 

(See  Figs.  20,  21,  and  22.) 

Miss  G.,  age  thirty-three  years.  Left  upper  eye- 
lid harbors  an  angioma  as  large  as  a  lien's  egg. 
A  picture  of  the  patient  taken  when  two  years  old 
shows  the  left  eye  closed  by  a  tumor  mass  in  the 
upper  eyelid.  The  sight  in  the  left  eye,  though 
weak,  is  normal,  the  tumor,  however,  robbing  the 
patient  of  its  usefulness. 

At  the  age  of  fifteen  years,  an  operation,  by  a 
skillful  surgeon,  was  performed.  The  operative 
measure  consisted  in  the  ligation  of  vessels  leading 
to  the  angioma.  There  was  a  slight  improvement, 
but  not  enough  to  open  the  eye. 

A  year  later,  the  condition  getting  worse,  i.  e., 
the  vascular  tumor  enlarging,  another  operation 
of  a  similar  nature  to  the  previous  one  was  per- 
formed.   No  improvement. 

In  October,  1914,  the  patient  went  to  a  New 
York  surgeon  to  subject  herself  to  the  radium 
treatment.  This  treatment  was  refused,  injury  to 
the  eye  being  feared.    An  operation  at  St.  Luke's 


56  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 


Fig.  20. — Miss  G.  A  typical  angioma  of  the  left  upper  eyelid 
since  babyhood.  Three  extensive  operative  measures  were  un- 
successful. The  condition  of  the  cicatricial  tissue  resulting  from 
these  operations  inhibited  to  some  extent  the  action  of  the  boil- 
ing water.  However,  three  injections  covering  a  period  of  seven 
months  brought  about  a  most  gratifying  result.  (See  detailed 
history.) 


TREATMENT    WITH    BOILING    WATER 


.)< 


Hospital  was  performed  instead.  This  operation 
gave  considerable  improvement.  Patient  was  able 
to  slightly  elevate  the  upper  eyelid. 


Fig.  21.— Miss  G.  Full  view  of  ease  shown  in  Fig.  20.  The 
result  after  three  injections  of  boiling  water  covering  a  period 
of  seven  months. 


This  improvement  lasted  four  months,  when  the 
blood  tumor  again  began  to  show  evidence  of 
enlarging. 


58 


CAVERNOUS    AND    FLEX  I  FORM    ANGIOMATA 


Iii  July,  when  I  saw  the  patient,  a  bluish  mass, 
very  soft  to  the  touch  and  about  as  large  as  a 
hen's  egg,  appropriated  the  upper  eyelid. 


fig.  22. — Miss  G.  Lateral  view  of  case  shown  in  Figs.  20 
and  21.  The  result  after  three  injections  of  boiling  water  cover- 
ing a  period  of  seven  months. 


There  were  numerous  scars  in  the  immediate 
vicinity  of  the  eye,  evidences  of  former  opera- 
tions.    There   was   a   very   conspicuous   cicatrix 


TREATMENT    WITH    BOILING    WATER  59 

along  the  orbital  ridge,  evidently  the  remains  of 
an  attack  on  the  supraorbital  artery. 

The  location  of  the  angioma  made  the  boiling- 
water  treatment  a  rather  hazardous  undertaking. 
Under  extraordinary  precautions,  three  injections 
were  given,  covering  a  period  of  seven  months 
(the  first  injection  was  given  July,  1915,  the  last 
February  1,  1916).  Owing  to  the  great  amount  of 
cicatricial  tissue  about  the  angiomatous  area,  the 
influence  of  the  boiling  water  was  to  some  extent 
interfered  with.  Nevertheless,  the  angioma  was 
made  to  disappear.  The  patient  is  now  able  to 
open  her  eye  to  two-thirds  normal.  The  color  of 
the  skin  is  almost  normal. 

The  sight  of  the  eye,  which  at  first  was  very 
weak,  is  being  gradually  restored  with  the  aid  of 
a  proper  lens. 

Case  History  of  Mr.  F.  in  Detail 

(See  Figs.  23  and  24.) 

A  carriage  painter,  never  seriously  sick,  was 
referred  to  me  by  Dr.  C,  Quincy,  Illinois. 

As  far  back  as  fifteen  years^  he  had  experienced 
attacks  of  dizziness.  During  the  last  two  years  he 
had  been  unable  to  follow  his  trade  as  carriage 
painter  on  account  of  the  severity  of  these  at- 
tacks. Has  had  a  small  swelling  behind  his  ear  as 
long  as  he  could  remember.  Four  years  ago  the 
swelling  had  grown  to  such  a  size  that  it  crowded 


GO 


CAVERNOUS    AND    FLEX I FORM    ANGIOMATA 


Fig.  2'.i. — Mr.  F.,  age  thirty-two  years.  Cirsoid  aneurysm  be- 
hind rijiht  ear  extending  well  down  on  neck.  This  patient  had 
been  subjected  to  a  surgical  measure  with  almost  fatal  results. 
Two  injections  were  sufficient  to  cause  obliteration  of  the  an- 
gioma. First  injection,  March  14,  1909,  6  ounces.  Second  in- 
jection, April  18,  1909,  -4  ounces.  Tumor  mass  disappeared  by 
June  1,  1909.     (See  detailed  history.) 


TREATMENT    WITH    BOILING    WATER 


61 


Fig.   24.— Mr. 
June  1,  1909. 


F.     Appearance   of   patient    shown   in   Fig.   23, 


62  CAVERNOUS    AND    PLEXTFORM    ANGIOMATA 

his  right  ear  forward  and  extended  into  his  scalp 
and  down  upon  his  neck. 

The  condition  of  the  tumor  mass  when  he 
consulted  me,  March,  1900,  presented  these  char- 
acteristics: Extending  from  the  midparietal  re- 
gion near  the  center  of  ossification  on  the  right 
side  down  to  the  clavicular  region,  the  tumor  oc- 
cupied the  entire  right  half  of  the  occipital  region, 
crowding  the  right  ear  markedly  forward.  The 
contour  of  the  tumor  was  clearly  defined.  The 
mass  proper  was  elevated  to  a  level  with  the  helix 
of  the  ear.  That  portion  of  the  tumor  involving 
the  neck  was  of  a  bluish  discoloration.  Upon  pal- 
pation a  distinct  pulsation  and  a  bruit  were  readily 
detected. 

With  the  application  of  pressure  the  contents 
of  the  swelling  could  be  forced  out  easily.  Upon 
releasing  the  pressure  the  tumor  promptly  reap- 
peared. With  touch  the  roughened  bone  margins 
and  many  irregularities  of  the  skull  underlying  the 
tumor  could  be  distinctly  discerned.  This  destruc- 
tion of  bone  was  caused  by  attrition  of  the  pulsat- 
ing mass. 

About  the  lower  pole  of  the  tumor  were  a  num- 
ber of  cicatrices,  the  result  of  an  attempted  opera- 
tion. The  patient  informed  me  that  he  almost 
perished  from  loss  of  blood  when  the  operation 
was  undertaken. 

The  condition  of  this  patient  was  one  of  extreme 
distress.    The  ringing  and  noises  in  his  right  ear 


TREATMENT    WITH    B01LIXG    WATEK  0O 

were  incessant.  He  was  unable  to  be  on  his  feet  on 
account  of  vertigo  and  was  compelled  to  sleep  in 
a  sitting  posture. 

An  attempt  was  made  to  administer  an  anes- 
thetic preparatory  to  the  injection  of  boiling  water. 
This,  however,  was  found  to  be  too  hazardous  a 
procedure,  the  influence  upon  the  tumor  mass  be- 
ing such  that  it  appeared  as  though  it  would 
burst. 

The  injection  of  hot  water  was  made  without  an 
anesthetic,  and  about  six  ounces  were  introduced. 
In  making  the  injection,  all  factors  of  safety  were 
considered:  the  scalp  had  been  shaved  and 
cleaned,  and  during  the  injection  peripheral  com- 
pression was  diligently  exercised. 

The  needle  was  first  introduced  at  the  lower 
pole  in  the  neighborhood  of  the  vessels  that  led 
.into  the  tumor.  As  soon  as  there  was  evidence  of 
coagulation,  following  the  injection,  the  needle 
was  withdrawn  and  reinserted  into  the  tumor  ;it 
a  different  site.  The  needle  was  introduced  about 
one-eighth  inch  from  the  mass.  In  this  manner 
the  whole  of  the  tumor  base  was  injected.  After 
six  ounces  of  hot  water  had  l^een  introduced  into 
the  mass  it  ceased  to  pulsate.  While  the  injec- 
tions were  being  given,  cloths  wrung  out  in  ice 
water  were  frequently  applied  to  the  mass,  which 
had  become  quite  hot. 

The  condition  of  the  patient  following  the  first 
injection,  exclusive  of  the  enormous  swelling  that 


()4  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

followed  (the  edema  involved  the  right  side  of  the 
face,  closing  the  right  eye,  and  encroached  upon 
the  neck,  throat,  and  chest),  was  very  encourag- 
ing. He  appeared  more  comfortable,  the  ringing 
in  his  ear  had  ceased,  and  he  was  able  to  lie  in 
bed.  At  the  end  of  four  weeks  the  growth  had 
diminished  to  less  than  half  its  size.  The  patient 
could  sleep  well  and  was  able  to  walk  about  with- 
out experiencing  dizziness.  A  second  injection  of 
about  four  ounces  of  hot  water  was  given  at  that 
time.  Six  weeks  later  the  tumor  mass  had 
practically  disappeared,  excepting  a  small  mass 
the  size  of  a  pigeon's  egg  at  the  angle  of  the  man- 
dible which  had  the  appearance  of  an  enlarged 
gland.  An  attempt  was  made  to  inject  it,  but  the 
substance  was  found  to  be  too  resistant. 

Case  History  of  Miss  S.  in  Detail 

(See  Figs.  25  and  26.) 

Always  in  good  health,  with  splendid  physical 
proportions,  suffered  much  from  periods  of 
marked  depression.  Since  childhood  had  a  small 
bluish  spot  on  her  upper  lip  and  immediately  be- 
low left  eye  upon  malar  prominence.  Seven  years 
ago  the  bluish  spot  on  the  lip  began  to  enlarge. 
It  continued  to  grow  very  gradually  and  was  the 
size  of  a  tangerine  when  she  presented  herself 
to  me  June  6,  1906. 

This  was  the  condition  of  her  face.    The  right 


TREATMENT    WITH    BOILING    WATER 


65 


Fig.  2."). — Miss  S.,  age  twenty-four  years.  Angioma  of  left 
cheek  and  upper  lip.  Ligation  method  with  loops  of  silk  tried 
and  failed.  Five  injections  of  boiling*  water  and  one  injection 
of  alcohol  obliterated  the  tumor  mass.  First  injection,  June  25, 
1906,  4  ounces.  Second  injection,  August  2,  1906,  3  ounces. 
Third  injection,  August  18,  1906,  2  ounces.  Fourth  injection, 
August  30,  l!?06,  1  ounce.  Fifth  injection,  September  25,  1906, 
I  ounce.  Sixth  injection,  October  8,  1906,  1  ounce.  Alcohol 
was  substituted  for  boiling  water  on  account  of  fear  of  too 
great  a  contraction  with  a  possible  deformity  about  the  lip. 
(See  detailed  history.) 


66  CAVERNOUS    AND    PLEXIFORM    AX(i  K  ).M  ATA 

side,  excepting  two-thirds  of  the  portion  of  the 
upper  lip,  was  normal.  The  left  side  showed  a 
marked  swelling  of  the  cheek  which  pushed  up  the 
lower  eyelid  and  encroached  upon  the  left  ala  of 
the  nose.  About  the  malar  prominence  was  an 
elevated  bluish  spot  as  large  as  a  pea.  The  left 
nostril  was  considerably  flattened,  about  one-half 
normal.  Two-thirds  of  the  cheek  showed  involve- 
ment in  a  tumor  mass  that  hung  down  over  the 
under  lip  within  one-quarter  inch  of  the  margin 
of  the  lower  jaw.  The  tumor  mass  was  of  a 
dark  blue  discoloration  and  was  convoluted.  Upon 
stooping,  this  mass  would  increase  in  size  very  per- 
ceptibly. The  swelling  was  soft,  the  skin  covering 
it  appearing  very  thin  to  the  touch.  Upon  ]  pres- 
sure it  could  readily  be  made  smaller  by  forcing 
the  blood  out  of  it.  The  evidence  that  there  were 
cavities  filled  with  fluid  was  unmistakable  to  the 
touch.  The  protrusion  of  the  tumor  was  such  that 
it  was  on  a  level  with  a  line  drawn  from  the  tip  of 
the  nose  across  the  cheek  and  down  to  the  chin. 
The  lower  lip  and  the  chin  showed  atrophic 
changes  corresponding  to  the  shape  and  contour 
of  the  tumor,  caused  by  pressure  of  the  overhang- 
ing mass.  The  incisor  and  canine  teeth  of  the  up- 
per jaw  had  long  been  destroyed  by  the  constant 
attrition  of  the  tumor.  Within  the  mouth  there 
could  be  seen  large  bluish  masses  of  mucous  mem- 
brane lying  between  the  molar  teeth  and  filling 
about  one-third  of  the  cavity  of  the  mouth,  caus- 


TREATMENT    WITH    BOILING    WATER  67 


Fig.  26. — Miss  S.  Appearance  of  patient  shown  in  Fig.  25, 
December  1,  1906.  A  slight  scarring  of  upper  lip  occurred,  the 
result  of  a  superficial  slough.    The  scar  was  excised  a  year  later. 


68  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

ing  an  impediment  of  speech.  Fear  of  biting  this 
mass  during  mastication  and  causing  free  bleed- 
ing was  a  constant  source  of  danger.  It  was  a 
great  discomfort  to  the  patient  because  of  the  dif- 
ficulty in  eating.  The  patient  carried  the  tumor 
in  a  sling  partly  because  it  relieved  the  weight 
and  partly  because  it  hid  from  view  the  unsightly 
mass. 

Having  had  no  previous  experience  with  the 
hot-water  injection,  I  spoke  very  discouragingly 
to  her  because  I  did  not  know  how  much  good  or 
how  much  harm  I  might  be  able  to  do  her  should 
I  undertake  to  interest  myself  in  her  behalf.  She 
had  consulted  a  number  of  physicians,  good  and 
bad,  during  the  past  six  years,  seeking  relief,  but 
invariably  returned  home  downhearted  and  dis- 
couraged. 

The  idea  that  occurred  to  me  at  first  was  to  re- 
duce the  pendulous  part  of  the  tumor  with  the  pro- 
cedure that  incurred  the  least  amount  of  risk.  I 
thought  this  to  be  the  ligation  method — strangula- 
tion by  introducing  loops  of  silk  subcutaneously 
along  the  mucocutaneous  margin  of  the  lip.  With 
a  very  small  cambric  needle  I  ligated  the  lower 
third  of  the  tumor.  Small  as  the  punctures  were, 
the  bleeding  was  most  obstinate,  continuing  for 
sixteen  hours.  With  the  aid  of  ice  and  pressure  it 
was  checked.  The  experiment  demonstrated  that 
it  was  not  the  procedure  to  be  followed.  The 
threads  became  infected  and  were  removed  on  the 


TREATMENT    WITH    BOILING    WATER  69 

fifth  day.  After  nine  days  the  infection  had  sub- 
sided. The  condition  remained  the  same,  except- 
ing that  about  one-half  inch  of  the  lip  on  the  right 
of  the  median  line  had  contracted;  furthermore, 
hard  nodules  could  be  felt  throughout  the  por- 
tion that  had  been  ligated. 

The  condition  as  it  presented  itself  after  two 
weeks  gave  me  considerable  encouragement,  and 
I  concluded  to  resort  to  the  treatment  of  injecting 
boiling  wafer.  The  risks  seemed  to  increase  while 
I  was  debating  with  myself  as  to  the  advisability 
of  using  this  method,  and  I  spoke  very  frankly  to 
the  patient  of  what  might  happen.  This  case 
seemed  to  me  to  be  one  particularly  prone  to  risks, 
inasmuch  as  so  much  mucous  membrane  had  to  be 
dealt  with.  To  inject  boiling  water  into  spaces 
filled  with  blood  seemed  to  me  an  operation  not 
.free  from  danger. 

The  first  injection,  under  aseptic  precautions, 
was  made  on  June  25,  1906.  Under  ether  narcosis, 
four  ounces  of  boiling  water  were  injected  into 
the  tumor.  A  small  aspirating  needle,  three  inches 
in  length,  was  inserted  into  the  swelling  through 
healthy  skin  on  the  right  cheek,  about  one-eighth 
of  an  inch  distant  from  the  tumor  margin  and 
about  one-half  inch  below  the  nose.  In  making 
these  injections,  the  advice  of  Dr.  Wyeth  was 
closely  followed.  All  of  the  tumor  was  injected 
excepting  the  portion  on  the  inside  of  the  cheek. 
About  ten  minutes  were  required  to  inject  the 


70  CAVERNOUS    AND    PLEXIFORM    ANdlo.MATA 

four  ounces  of  boiling  water.  Time  was  lost  by 
not  having  been  able  to  obtain  a  Wyeth  syringe. 
An  ordinary  glass  syringe  holding  two  ounces  was 
used,  the  aspirating  needle  being  attached  to  the 
syringe  with  rubber  tubing.  It  was  a  clumsy  way 
of  doing  this  work,  but  it  answered  the  purpose 
satisfactorily.  The  handling  of  boiling  water  is  a 
rather  delicate  task. 

While  the  injection  was  being  made,  the  pa- 
tient's face  was  protected  in  the  immediate  vicin- 
ity of  the  needle  so  that  the  boiling  water  which 
was  being  forced  out  at  the  needle  junction  by  the 
confined  steam  would  not  scald  the  skin.  The 
hands  of  the  operator  were  protected  by  a  folded 
towel.  It  did  not  serve  the  purpose  well,  and  to 
those  who  have  occasion  to  handle  boiling  water  I 
would  suggest  the  use  of  heavy  duck  gloves. 

To  anticipate  as  far  as  possible  any  danger 
from  embolism,  peripheral  compression  was 
made.  In  introducing  the  needle,  it  was  carried 
through  the  mass  till  the  point  could  be  distinctly 
felt  through  the  skin.  The  withdrawing  of  the 
needle  about  one-half  inch  gave  a  reasonable 
amount  of  assurance  that  the  boiling  water  could 
be  forced  gently  into  the  affected  area  with 
little  danger  of  provoking  sloughing.  The 
needle  was  introduced  in  four  different  places  at 
various  angles.  In  some  places  the  integument 
turned  pale,  in  others  an  ashen  gray,  while  the 
water  was  being  injected  into  the  tumor.     The 


TREATMENT    WITH    BOILING    WATER  (  L 

beat  of  the  water  could  be  very  distinctly  felt 
through  the  tissues — they  were  hot. 

After  the  operation  the  patient  was  put  to  bed. 
The  following  day  the  left  side  of  the  face  was 
very  much  swollen,  but  not  painful.  The  left  eye 
was  partially  closed.  A  large  blister  had  formed 
along  the  mucous  border  of  the  lip.  The  tumor 
felt  hard  to  the  touch.  There  was  a  slight  rise  in 
i  em]  icrature  (99.6° ) .  Two  days  later  the  tempera- 
ture returned  to  normal.  The  patient  left  the  hos- 
pital on  the  fifth  day.  On  July  26  a  large  scab 
which  had  formed  on  the  lip  margin  was  removed. 
The  whole  tumor  was  hard,  excepting  about  two- 
thirds  of  the  tumor  mass  inside  of  the  cheek. 
Diminution  by  granular  metamorphosis  had  re- 
duced the  tumor  to  one-half  its  original  size.  I 
wish  to  state  here  that  a  linear  sloughing  of  the 
skin  occurred  which  extended  from  the  ala  of  the 
Left  nostril  to  the  margin  of  the  lip.  It  resulted  in 
a  cicatrix  that  was  but  slightly  disfiguring.  This 
scar  was  removed  subsequently. 

On  August  2,  under  ether  anesthesia,  the  buccal 
mucous  membrane  was  injected  with  three  ounces 
of  boiling  water.  The  outcome  was  most  favor- 
able, only  a  small  slough  resulting. 

On  August  18,  under  ether  anesthesia,  two 
ounces  of  hot  water  were  injected  into  the  lip. 
Some  difficulty  was  encountered  in  introducing 
the  needle  on  account  of  the  hardened  condition 
of  the  tissues. 


72  CAVERNOUS    AND    PLEXIFORM    ANGIOMATA 

On  August  30,  without  anesthesia,  one  ounce  of 
boiling  water  was  injected  into  the  buccal  mass. 

On  September  15  conditions  began  to  take  on  a 
normal  appearance. 

On  September  25,  without  anesthesia,  one  ounce 
of  boiling  water  was  injected  into  the  outer  por- 
tion of  the  lip,  which  still  appeared  quite  large. 
Ten  days  later  the  lip  was  almost  normal. 

On  October  8  an  injection  of  one  ounce  of  alco- 
hol* caused  the  lip  to  assume  so  nearly  a  normal 
condition  that  further  intervention  was  deemed 
unnecessary  and  the  patient  was  discharged. 


*In  substituting  alcohol  for  boiling  water,  I  wish  to  state  that  I  feared 
too  much  contraction  might  take  place  with  the  use  of  boiling  water  and 
cause  a  deformity  of  the  lip.  In  this  assumption  a  more  extensive  experience 
now  convinces  me  that  I  was  in  error.  The  alcohol  injection  was  not  nec- 
essary, and  did  not  influence  the  condition.  It  was  the  time  given  to 
metamorphosis   that   brought   about   the    result. 


INDEX 


Advisability  of  giving  an  anes- 
thetic, 51 
Aneurysm,  cirsoid,  52 
Angioma,    nevus    complicating, 
41 

time    required    to    disappear 
after  an  injection,   50 
Angiomata,   behavior   of,   after 
injection    of    hot    water, 
50,  51 

capillary,  29 

cavernous,  IS 

classification  of,  17 

location   of,   19 

pain  in  connection  with,  19 

of  the  tongue,  dangers  of  in- 
jecting, 35 

plexiform,  clinical  character- 
istics of,  28 

theory  of,  17 

various    methods    other    than 
surgical  used  to  destroy, 
32 
Arrangement       of       operating 
mom,  45 

B 

Barensprung's  view,  29 
Behavior  of   an  angioma  after 

hot-water    injection,    50, 

51 


Boiling  water  used  in  conjunc- 
tion with  Pacpielin  cau- 
tery, 41 

Boiling  water,  Wyeth  method  of 
injecting,  32 


Capillary  form  of  angioma,  29 

Care  in  injecting  an  angioma  of 
the  lip,  35 

Care  in  injecting  tip  of  the 
nose,  49 

Characteristics  of  cavernous  an- 
giomata, 18 

Characteristics  of  plexiform 
angiomata,  19 

Cicatricial  tissue,  a  serious  ob- 
stacle to  the  injection  of 
hot  water,  59 

Cirsoid  aneurysm,  52 

Classification  of  angiomata,  17 

Clinical  characteristics  of  a  cav- 
ernous angioma,  18 

Cork-protected  needle,  45 


D 

Danger  of  injecting  angioma  on 

the  tongue,  35 
Dangers     of    injecting    boiling 

water   into    an    angioma, 

36    * 


73 


74 


INDEX 


Edema  of  adjacent  tissues  fol- 
lowing injection,  50 


Pace,  protection  of,  45 
Force  used  in  injecting  hot  wa- 
ter, 45-48 

H 

Hands,     protection     of,     while 
making  injection,  43 


injection  of  boiling  water,  dan- 
gers of,  36 
syringe  for,  41 
technic  for,   41 
Wyeth  method,  32 
Injection   of  hot  water,   edema 
of    adjacent  tissues   fol- 
lowing, 50 
force  used  in,   45-48 
quantity    to   be    used    at    one 

time,  49 
time  consumed  in  making  the, 
49 
Injections  of  hot  water,  subse- 
quent,    when     indicated, 
49 
Introduction  of  the  needle  and 
force    used   in    injecting 
hot  water,  45-48 


Jacketed  syringe,  4J 


Lip,  care  in  injecting  angioma 

on  the,  35 
Location  of  angiomata,  19 
Larry's  theory,  30 

N 

Needle,  cork-protected,  45 
introduction  of,  45-48 
size  and  character  of,  43 
Nevus     complicating      an      an- 
gioma, 41 
Nose,  care   in   injecting  tip   of 
the,  49 

O 

Operating     room,     arrangement 
of,  45 


Pain  in  connection  with  an- 
giomata, 19 

Paquelin  cautery,  boiling  water 
used  in  conjunction  with, 
41 

Plexiform  angiomata,  clinical 
characteristics  of,  28 

Protection  of  hands  while  mak- 
ing injection,  43 

Protection  of  patient's  face,  45 


Quantity  of  hot  water  to  lie  in- 
jected at  one  time,  49 


INDEX 


75 


R 

Ribbert  on  the  genesis  of  an- 
giomata, 30 

S 

Salient  points  to  be  considered 
in  the  treatment  of  an- 
giomata,  31 

Simon's  theory,  30 

Size  and  character  of  needle, 
13 

Strangl's  argument,   30 

Subsequent  injections,  when  in- 
dicated, 49 

Syringe  for  injecting  boiling 
water,  41 

Syringe,  jacketed,  43 


T 


The  ny   of   angiomata,   17 

Time  consumed  in  making  in- 
jection, 49 

Time  required  for  an  angioma 
to  disappear  after  injec- 
tion, 51 

Tongue,  danger  of  injecting  an 
angioma  of  the,  35 


V 

Various  methods  other  than 
surgical  used  to  destroy 
an  angioma,  32 

Virehow's  theory  of  the  origin 
of  angiomata,  30 

W 


Teehnic     of     injecting     boiling       Wyeth  method  of  injecting  boil- 
water,  41  ing  water,  32 


6  It 


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COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

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The  treatment  of  cavernous  and  plexlform 


2002272652 


